Heterogeneity in HeartMate 3 implanting center infection management reveals opportunities for quality improvement and best practice initiatives during left ventricular assist device support.

BACKGROUND

There is marked variability in device-related (DR) infection frequencies across HeartMate 3 (HM3) centers. The goal is to correlate center driveline (DL) management and infection mitigation practices with DR-infection development, laying foundation for development of best practice recommendations for one facet of HM3 patient care.

METHODS

Coordinators at 30 HM3 centers were surveyed about center practices for infection prophylaxis, intraoperative DL placement and postoperative care, and infection mitigation. Early (≤90 days) and late (>90 day) center DR-infection frequencies were calculated from Society of Thoracic Surgeons Intermacs data linkage. Correlations between center practice patterns and incident DR-infection were examined with multivariable Cox modeling (clustering adjusted hazard ratio [aHR]).

RESULTS

Within Intermacs (3,725 patients), 1-year freedom from DR-infection was 87% (80.6-87.3%). Initially, DL dressing changes were performed daily, weekly, and variably at 48%, 21% and 31% of centers. After 4 weeks, 57% deescalated dressing changes to weekly. Chlorhexidine cleanser with a silver-impregnated dressing (Chl-Sil) was standard at 52.7% of programs; 47.3% used chlorhexidine alone or other supplies. Use of Chl-Sil was associated with reduced early (aHR 0.48, p=0.004) and late (aHR 0.64, p=0.02) DR-infection while frequent dressing changes conferred higher late DR-infection (aHR 1.4, p=0.05). Antibiotic prophylaxis, DL tunneling, and diabetes practices did not correlate with DR-infection.

CONCLUSIONS

Given the burden of DR-infections, best practice recommendations are needed to standardize care. Application of Chl-Sil DL dressings could be a first step in achieving care standardization, while frequent dressing changes following DL incorporation should be avoided.